Provider Demographics
NPI:1053665711
Name:WALTERS, DONNA R (CNM)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:R
Last Name:WALTERS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6477
Mailing Address - Country:US
Mailing Address - Phone:618-997-5266
Mailing Address - Fax:618-997-5285
Practice Address - Street 1:3408 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6477
Practice Address - Country:US
Practice Address - Phone:618-997-5266
Practice Address - Fax:618-997-5285
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009739363LW0102X
IL209017028367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health